Management of patients presenting with otorrhoea: diagnostic and treatment factors.

OtItIs externa Otitis externa is an inflammation of the external auditory canal, characterised by erythema and oedema. It has a 12-month period prevalence of 1.3% in females and 1.2% in males.1 Patients typically present with otalgia and an infected discharge. However, there is generally no change in hearing unless the entire canal is obstructed. Movement of the tragus results in significant discomfort. On otoscopy the canal appears narrowed and inflamed, with infected squamous debris lining the walls. Initial treatment centres around the administration of topical medications and, to minimise further irritation, patients should be advised not to poke anything into the ears or get them wet. They should also avoid swimming and getting their head wet. If there is a chance that the ears may get splashed, cotton wool coated with Vaseline® can be used as an ear plug. Topical preparations containing an antimicrobial with a steroid are an effective treatment, and in general there is no difference between the various types of preparation.2 However, choice is important if a fungal infection is suspected, on the basis of severe pruritus and hyphae within the external canal. Take a swab for culture and sensitivity, and use a preparation such as Locorten-Vioform®, which treats both bacterial and fungal infections. Provided there is neither systemic infection nor serious underlying disease, there is no need for systemic antibiotics.3 If symptoms do not improve an ENT referral for aural microsuction is appropriate.4 Patients with severe pain may require admission. External ear infection can spread, either as a cellulitis or perichondritis of the outer ear, or to the skull base, causing a condition known as necrotising otitis externa. Both conditions require urgent systemic antibiotics to control the spread of infection. Urgent ENT referral is also needed if a patient with otitis externa has a cranial nerve palsy (indicating potential bone involvement), granulations within the auditory canal, erythema and swelling of the pinna, or where there are worsening symptoms in a vulnerable (for example, a person with diabetes), or immunocompromised patient.